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Keratosis pilaris and variants
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Keratosis pilaris (KP) is a common inherited disorder characterized by tenacious keratin plugging of follicular orifices affecting characteristic body sites. It typically presents in childhood on the extensor aspects of the upper arms, anterior surfaces of the thighs, and lateral aspects of the cheeks. In more extensive cases, it may extend onto the distal extremities, shoulders, back, and buttocks. Perifollicular erythema is common, and a background of erythema on the cheeks may also be seen in keratosis pilaris rubra (KPR). Other variants of KP include erythromelanosis follicularis faciei et colli (EFFC) and keratosis pilaris atrophicans (KPA), which includes keratosis pilaris atrophicans faciei (ulerythema ophryogenes), keratosis follicularis spinulosa decalvans (KFSD), folliculitis spinulosa decalvans (FSD), and atrophoderma vermiculatum; these subtypes are also addressed in this chapter.
KP may be seen in conjunction with other skin disorders, such as atopic dermatitis; it may also arise or become exacerbated in states of androgen and insulin dysregulation, such as diabetes, obesity, and pregnancy, and may be seen in conjunction with malnutrition. Extensive disease has also been observed in patients with Down syndrome and with drugs.
Management Strategy
KP is commonly asymptomatic and often does not require treatment. Those with extensive or symptomatic involvement often desire treatment, and even mild KP may cause patients cosmetic distress. It may become less prominent with age, even without directed therapy.
Initial treatments aim to decrease roughness and follicular accentuation. Keratolytic agents , such as glycolic acid, ammonium lactate, salicylic acid (SA), and urea-containing humectants, are the mainstays of treatment. Use of a compound of 2% SA in 20% urea cream or 6% SA in propylene glycol combines the properties of an emollient with a keratolytic agent. Twice-daily application of one of these agents for at least a 3-week trial is recommended. Vigorous scrubbing can lead to irritation and should be avoided. Once adequate improvement has been achieved, maintenance therapy of weekly or twice-weekly application of a topical keratolytic agent is recommended.
Topical retinoids may be utilized and should be gradually up-titrated to avoid irritation. Tazarotene 0.05% cream has been shown to decrease pruritus, erythema, and roughness in a placebo-controlled trial of KP. Oral isotretinoin has been helpful in some patients with ulerythema ophryogenes, atrophoderma vermiculatum, and KFSD.
If a significant inflammatory component is present, treatment with a medium-potency topical corticosteroid in an emollient base can be utilized. Once inflammation has abated, corticosteroids should be discontinued, and treatment should transition to keratolytics.
Cutaneous laser and light therapies have been utilized for several variants of KP (Table 125.1 ).
Specific Investigations
Table 125.1
Cutaneous laser and light therapies in the treatment of keratosis pilaris (KP) and variants
| KP variant | Modality | Details |
|---|---|---|
| Keratosis pilaris spinulosa decalvans (KPSD) | Non-Q–switched, high-energy, pulsed ruby laser | Five treatments at fluences of 19–21 J/cm 2 at 6-week intervals led to a significant reduction of inflammation in treated areas, at the expense of a persistent diminution of hair growth at 8-month follow-up in one patient with KPSD a |
| Keratosis follicularis spinulosa decalvans (KFSD) | 800-nm diode laser | Case report of patient treated with five sessions at pulse width 30 ms, fluence 9 J/cm 2 with smoothening of the skin and complete resolution of inflammation without recurrence after 2.5 years b |
| KP atrophicans (KPA) | 585-nm PDL | 12 patients received 2–8 treatments at fluences ranging from 6 J/cm 2 to 7.5 J/cm 2 , resulting in improvement in erythema but not texture c |
| Keratosis pilaris rubra (KPR) | 532-nm potassium titanyl phosphate (KTP) laser | Fluences of 12–14 J/cm 2 and pulse width of 510 ms were used, resulting in cosmetic clearance of keratotic papules and reduction in facial erythema d |
| KPR | PDL | Case report of seven treatments at fluence of 12 J/cm 2 and pulse duration 3 ms, with marked improvement in erythema and follicular hyperkeratosis for 9 months e In a retrospective study, eight adolescent patients received between one and four PDL treatments. All patients reported improvement in erythema, with two lost to follow-up f |
| KPA | Intense pulsed light (IPL) | Four patients were treated with 5–9 sessions of IPL resulting in over 75% reduction in erythema, reduced roughness, and no recurrence after 10 months g |
| KPR or KPA | PDL | 10 patients with either condition were treated with 2–7 sessions of PDL with fluence 5–9 J/cm 2 and pulse duration 0.5–1.5 ms, resulting in >75% resolution of erythema, with one case of postinflammatory hyperpigmentation h |
| KP | Q-switched 1064-nm Nd:YAG laser | 12 patients were treated with 10 sessions every 2 weeks, resulting in improvements in skin texture and dyspigmentation i |
| KP | Long-pulsed 1064-nm Nd:YAG laser | 18 patients underwent three sessions with 30-msec pulse width and fluence 34 J/cm 2 , with the contralateral arm serving as a control. Significant improvements in erythema and number of keratotic papules reported j |
| KP | FRAC3 1064-nm Nd:YAG laser | 23 of 24 patients completed four treatments and experienced statistically significant improvement in skin roughness measured by Antera 3D and subjective improvement in roughness, erythema, and hyperpigmentation compared with controls at 16 weeks k |
| KP | Combination of PDL, long-pulsed 755-nm alexandrite laser, and microdermabrasion | 26 patients were treated using combination laser therapy. Pretreatment and posttreatment photographs and patient satisfaction rates were compared 3 months after treatment. Significant improvements were noted in erythema, skin texture, and discoloration l |
| KP | 810-nm diode laser | After three treatments, skin texture improved significantly, but baseline erythema was not improved in this blinded, randomized, split-body, placebo-controlled trial m |
| KP | Fractional CO 2 laser | 12 weeks following a single treatment, physicians’ global assessment showed 30% of lesions on treated side had moderate-to-good improvement n Another prospective, single-blinded, split-body, placebo-controlled study of 60 patients demonstrated significant clinical and dermatoscopic improvement in KP lesions treated with two sessions of fractional CO 2 laser therapy 4 weeks apart compared to control areas treated with 10% urea o |
| KP | IPL | Of 24 patients, there was a statistically significant reduction of skin roughness as measured by Antera 3D and subjective improvement in roughness, erythema, and hyperpigmentation compared to controls at 16 weeks p |
| KP | Combination of fractional CO 2 laser and Q-switched Nd:YAG | Prospective, intraindividual study of 18 patients with comparison of baseline and postlaser clinical photographs. Blinded investigators did not agree upon the superior therapy, but patients reported the most satisfaction with combination therapy q |
| Erythromelanosis follicularis faciei et colli (EFFC) | Dual 585-nm PDL and 1064-nm Nd:YAG laser | Split-face case report using dual PDL and Nd:YAG, with significant reduction in facial erythema after five sessions r |
a Chui CT, Berger TG, Price VH, et al. Recalcitrant scarring follicular disorders treated by laser-assisted hair removal: a preliminary report. Dermatol Surg 1999; 25:34–7.
b Bhoyrul B, Sinclair R. Successful treatment of keratosis follicularis spinulosa decalvans with an 800-nm diode laser. Dermatol Surg 2020;46:849–50.
c Clark SM, Mills CM, Lanigan SW. Treatment of keratosis pilaris atrophicans with the pulsed tunable dye laser. J Cutan Laser Ther 2000;2:151–6.
d Dawn G, Urcelay M, Patel M, et al. Keratosis rubra pilaris responding to potassium titanyl phosphate laser. Br J Dermatol 2002;147:822–4.
e Kaune KM, Haas E, Emmet S, et al. Successful treatment of severe keratosis pilaris rubra with a 595-nm pulsed dye laser. Dermatol Surg 2009;35:1592–5.
f Schoch JJ, Tollefson MM, Witman P, et al. Successful treatment of keratosis pilaris rubra with pulsed dye laser. Pediatr Dermatol 2016;33:443–6.
g Rodríguez-Lojo R, Pozo JD, Barja JM, et al. Keratosis pilaris atrophicans: treatment with intense pulsed light in four patients. J Cosmet Laser Ther 2010;12:188–90.
h Alcántara González J, Boixeda P, Truchuelo Díez MT, et al. Keratosis pilaris rubra and keratosis pilaris atrophicans faciei treated with pulsed dye laser: report of 10 cases. J Eur Acad Dermatol Venereol 2011;25:710–4.
i Park J, Kim BJ, Kim MN, et al. A pilot study of Q-switched 1064-nm Nd:YAG laser treatment in the keratosis pilaris. Ann Dermatol 2011;23:293–8.
j Saelim P, Pongprutthipan M, Pootongkam S, et al. Long-pulsed 1064-nm Nd:YAG laser significantly improves keratosis pilaris: a randomized, evaluator-blind study. J Dermatolog Treat 2013;24:318–22.
k Maitriwong P, Tangkijngamvong N, Asawanonda P. Innovative 1064-nm Nd:YAG laser significantly improves keratosis pilaris, a randomized, double-blind, sham-irradiation-controlled trial. Lasers Surg Med 2019 Nov 11 [Epub ahead of print].
l Lee SJ, Choi MJ, Zheng Z, et al. Combination of 595-nm pulsed dye laser, long-pulsed 755-nm alexandrite laser, and microdermabrasion treatment for keratosis pilaris: retrospective analysis of 26 Korean patients. J Cosmet Laser Ther 2013;15:150–4.
m Ibrahim O, Khan M, Bolotin D, et al. Treatment of keratosis pilaris with 810-nm diode laser: a randomized clinical trial. JAMA Dermatol 2015;151:187–91.
n Vachiramon V, Anusaksathien P, Kanokrungsee S, et al. Fractional carbon dioxide laser for keratosis pilaris: a single-blind, randomized, comparative study. Biomed Res Int 2016;2016:1928540. 2016 May 9 [Epub ahead of print].
o Ismail S, Omar SS. Clinical and dermoscopic evaluation of fractional carbon dioxide laser in management of keratosis pilaris in Egyptian type skin. J Cosmet Dermatol 2020;19:1110–20.
p Maitriwong P, Tangkijngamvong N, Asawanonda P. Intense pulsed-light therapy significantly improves keratosis pilaris: a randomized, double-blind, sham irradiation-controlled trial. J Clin Aesthet Dermatol 2019;12:E53–E57.
q Sobhi RM, Adawy NAH, Zaky IS. Comparative study between the efficacy of fractional CO 2 laser, Q-switched Nd:YAG laser (1064 nm), and both types in treatment of keratosis pilaris. Lasers Med Sci 2020 Jan 11 [Epub ahead of print].
r Li YH, Zhu X, Chen JZS, et al. Treatment of erythromelanosis follicularis faciei et colli using a dual-wavelength laser system: a split-face treatment. Dermatologic Surg 2010;36:1344–47.
The prevalence of cutaneous manifestations in young patients with type 1 diabetes
Pavlović MD, Milenković T, Dinić M, et al. Diabetes Care 2007; 30: 1964–7.
KP affected 12% of diabetic patients compared with 1.5% of healthy sex and age-matched subjects.
Other conditions associated with KP include high body mass index, ichthyosis, atopy, pregnancy, cardiofaciocutaneous syndrome, and hyperandrogenism in obese females. KP-like lesions have been observed in patients treated with vemurafenib for metastatic melanoma.
Keratosis pilaris atrophicans. One heterogeneous disease or a symptom in different clinical entities
Oranje AP, van Osch LD, Oosterwijk JC. Arch Dermatol 1994; 130: 500–2.
Patients with KPA are reported to have increased incidence of ocular abnormalities, including photophobia, corneal deposits, and juvenile cataracts.
This review also clarifies the confusing nosology of KP variants.
Red face revisited: disorders of hair growth and the pilosebaceous unit
Ramos-e-Silva M, Pirmez R. Clin Dermatol 2014; 32: 784–99.
This review includes epidemiology, clinical presentation, pathogenesis, and therapy of the inflammatory follicular keratotic syndromes.
Keratosis pilaris and its subtypes: associations, new molecular and pharmacologic etiologies and therapeutic options
Wang JF, Orlow SJ. Am J Clin Dermatol 2018; 19: 733–57.
This review details clinical characteristics and pathophysiology of KP and its subtypes, and evaluates topical, systemic, and energy-based therapies.
Epidermal permeability barrier in the treatment of keratosis pilaris
Kootiratrakarn T, Kampirapap K, Chunhasewee C. Dermatol Res Pract 2015; 205012: 1–5.
A blinded, prospective, randomized, split-side trial of 50 KP patients compared twice-daily 10% LA and 5% SA. Mean reduction of lesions from baseline was statistically significant for both LA and SA, with LA being statistically more effective after 3 months of use.
Evaluation of a sodium lactate and urea créme to ameliorate keratosis pilaris
Weber TM, Kowcz A, Rizer R. J Am Acad Dermatol 2004; 50(S1): 47.
A formulation containing sodium lactate and urea was tested on 32 subjects with KP, with statistically significant improvements in skin tone and roughness reported after 3–12 weeks.
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